Brian L. Badman MD Jonathan Levy MD Randall Otto MD Mark Mighell MD

1. Proximal Humeral Fractures Treated with Locked Plating and an Intramedullary Strut Allograft:A Retrospective Analysis Brian L. Badman MD Jonathan Levy MD Randall Otto MD Mark Mighell MD

2. Disclosures: • Brian Badman MD • Paid Consultant, Royalties, Investor UpEX • Paid Consultant DJO Surgical • Jonathan Levy MD • Paid Consultant DJO Surgical, Arthrex, Stryker Orthopaedics • Randall Otto MD • Honorarium DJO Surgical • Mark Mighell MD • Paid Consultant, Royalties, Investor UpEX • Paid Consultant DJO Surgical

3. Background • Locked plating: treatment option for proximal humeral fractures • Implant complications : screw cutout and varus relatively common • endosteal allograft strut for reduction and medial calcar restoration

4. Background Proximal Humeral Fracture Fixation: Locking Plate Constuct +/- Intramedullary fibular allograft Chow, Begum, Beaupre, Carey 2012 Jul;21(7):894-901 Locked Plating of the Proximal Humerus Using an Endosteal Implant Hettrich, Neviaser, Beamer et al; 2012; 26(4); 212-215 27 patients 23 fibula and 4 semitubular plates 96% patients maintained reduction Conclusion: Endosteal implant with locking plate can avoid varus collapse • 16 cadaver humerii • 8 locking plate + Fibula, 6 collapsed • 8 locking plate only, 0 collapsed • Loaded to failure or 25,ooo cycles • Conclusion: • Plate + Fibula better withstands varus loading

5. Hypothesis: • locked lateral plating combined with an intramedullary allograft for the treatment of proximal humerus fractures would be similar to published studies and mitigate varus collapse

6. METHODS • Minimum one year clinical f/u • 65 patients • avgage 68yrs • Retrospective analysis of all 2-,3- and 4-part fractures treated with locked plating and intramedullary allograft • 2part—19(30%) • 3part—33(50%) • 4part—13(20%)

7. Methods • Xrays reviewed by independent observer • associations between patient and fracture specific factors • age (>65 or < 65yrs) • fracture type (2, 3, or 4-part) • Hertel criteria (>8mm or <8mm medial hinge) • Gender • ASES score • shoulder rom using goniometer.

8. Results • AVG F/U 22 months (RANGE: 12-53) • Average ASES score: 79 (Range: 15-100) • Average ROM • FF: 125° (Range: 40°-180°) • External Rotation: 39° (Range: 0°-90°) • Hertel criteria—Medial Hinge • 46 (71%) <8mm • 19 (29%) >8mm • Mean humeral neck shaft angle: 127° (Range, 104°-145°) • 100% Union • Avg Time: 4.2m (range: 1.5-8m)

9. RESults • Overall Complication Rate: 18% (12/65) • Fracture malunion: 15% (10/65) • 2 greater tuberosity avulsions • 8 varusmalunions (12%) • 2 patients with varusmalunions also had screw penetration • Screw penetration: 6% (4/65) • Avascular necrosis: 3% (2/65) • no statistical difference in functional outcome, complication rate or incidence avnbased on age, gender, or fracture type.

10. Conclusion • Allograft strut helpful as reduction aid and initial stability in situations of metaphyseal and medial calcarcomminution • varuscollapse was not diminishedby use of an allograft strut • utility of this technique in “solving” this problem is questioned • Revision surgery harder • Avoidance of this complication is likely multifactorial related to technical factors (medial support, calcarscrews, etc) and patient factors (osteoporosis, patient compliance, etc)

11. THANK YOU